Follicular Unit Extraction – FUE

Automation FUE Still Not Ready For Primetime

FUE, or follicular unit extraction, is an ever-growing hair transplant method. It is not only gaining popularity, but also seems to be constantly developing in technology to improve surgical hair restoration capabilities overall. By nature, its individual follicle extraction was an improvement from other methods in invasiveness, recovery time, scarring, and hairline design. Of course, FUE has also seen somewhat of a tools race—the development of various extraction tools to get the job done as quickly, safely, and efficiently as humanly (or robotically) possible.

However, many of these new FUE machines are not yet advanced enough for the most advanced niche of FUE—body hair transplant (BHT). In recent years, follicular unit extraction paved the way for the development of BHT, a hair restoration technique that expands the donor supply to include almost all hair on the body. This advanced method still requires the use of a handheld tool.

Different FUE Machines

All FUE machines work on a punching mechanism, anywhere from .8mm to 1.2mm in diameter. Classic tools are handheld and rely on the steady, trained hands of a skilled surgeon. Handheld tools can be manual, with a rotary punch, or electrically powered. This is the only type of FUE machine currently available for use in body hair transplant. uGraft is one example of such a tool.


FUE Procedure Tools

Powered handheld FUE tool.

Other tools growing in popularity and use include ARTAS and NeoGraft. These FUE machines are both largely mechanized, with ARTAS being entirely robotic.

These systems can only be used on the scalp. At the moment, they  are not yet ready for the extremely advanced nature of body hair transplant, since they are unable to extract hair outside the traditional donor zone.

Why Handheld FUE Machines Are Ideal for Body Hair Transplant

BHT enables the use of hair from the nape of the neck, beard, shoulders, chest, stomach, arms, and legs. Surgeons using handheld FUE machines like uGraft are able to navigate these areas with minimal invasiveness and minimal scarring. In addition, with body hair follicles often being more curved in nature than scalp hair, keeping each graft in tact necessitates the eye and precision of a human hand.

F.U.E Hair Transplant Procedures For African American Patients

Techniques in Follicular Unit Extraction can be specialized for specific groups like African Americans. There are physiological distinctions that pertain not only to the hair shaft, but also the hair follicle  itself and its relationship with surrounding tissue. To create the best results, the hair doctor must be able to work effectively within the construct of these characteristics during the actual procedure.

Prior to performing an F.U.E. transplant on African American patients, the doctor must determine the transection rates in potential candidates. This is done through a preliminary F.U.E. test procedure to help decide whether or not the patient can undergo Follicular Unit Extraction.

Curved follicles tend to be more difficult to extract and risk higher rates of transaction, where the hair bulb becomes damaged during the removal process. They also face lower chances of survival when they are reinserted.

Another challenge of F.U.E. transplant performed on African American individuals is that the hair follicles are tightly attached to the surrounding tissue. Extricating these follicles can be difficult because of this.

The hair doctor must make sure to leave most of the donor hair follicles in tact during the surgery.

Despite these concerns, Follicular Unit Extraction offers the best surgical solution for hair replacement in African Americans. Scarring and the development of keloids is a risk factor for this population. While this is certainly a concern in strip surgery due to the use of a scalpel, it is practically a negligible issue   in the context of F.U.E.

One of the benefits of using curly hair in African American F.U.E. transplant is that it provides far greater coverage compared to other ethnicities. So a fewer number of grafts would be adequate for hair restoration.

African American Hair Transplant Procedures

Before and after pictures of FUE transplant performed on African American patient

Surgical Solutions For Ethnic Hair Loss

While hair loss happens across different ethnic groups, transplant procedures need to be very specialized to accommodate specific characteristics such as the nature of surrounding tissue, hair follicles, hair shafts and growth patterns.

The two ethnicities that require this level of discernment includes Asians and individuals of African descent.

Surgical Hair Loss Interventions for Ethnic Groups

Strip hair transplant methods have been the traditional form of surgical intervention since about the early 2000s. It involves removing a horizontal strip of hair bearing skin from the back of the head.

This strip is then cut into individual grafts to be transplanted into areas of the head that are depleted of hair.

However, patients of Asian or African heritage tend to scar very easily and develop keloids. Therefore this particular type of procedure is not ideal hair loss solution for these ethnic groups.

Follicular Unit Extraction offers a surgical alternative that does not entail the risk of prominent linear scars that would require longer hair styles to conceal them. This technique does not use a scalpel since the objective is to isolate individual grafts of follicles that contain natural groupings of 1-4 hairs. These follicles are then reinserted into bald regions of the scalp.

For individuals of Asian or African descent, addressing ethnic hair loss through Follicular Unit Extraction has the potential to give excellent results that addresses the specific needs of these ethnic groups.

Surgical Solutions for Hair Loss

before and after results of an F.U.E. hair restoration performed on an African American patient


Ethnic Hair Loss Surgical Solutions

Results of an F.U.E. hair restoration procedure performed on an Asian patient



The Evolution of Surgical Hair Replacement Techniques

The best way to achieve hair replacement is undoubtedly through surgery. While this is a more costly option, the results are permanent. And depending on the skill and technique used, the outcome more or less approximates a natural state of having a full head of hair.

Surgical techniques for hair transplantation  can be grouped as older techniques versus more modern techniques, such as F.U.E.

Older Surgical Hair Replacement Methods

Punch grafting is a hair replacement  technique which emerged around 1955. It uses a specialized instrument to punch out cylindrical shaped grafts of skin, “plugs” from the donor area. This not only leaves scars that look like dots, but the transplanted hair is tufted the way hair exits on the heads of dolls.

Temporo parieto occipital flap surgery has been used since 1969 to reconstruct the anterior (front) hairline by surgically pulling areas of the scalp with ample hair forward. This results in a horizontal scar around the top part of the forehead.

Scalp reduction which became popular in the 1970s is another older hair replacement technique where the surgeon surgically removes areas of the scalp and then stitches them together in order to reduce the area of baldness. This is done prior to inserting grafts of donor hair.

Modern Surgical Hair Replacement Methods

More modern hair replacement methods include

  1. F.U.T. (Follicular Unit Transplant), also known as strip surgery or F.U.S.S. (Follicular Unit Strip Surgery)
  2. F.U.E. (Follicular Unit Extraction)


In strip surgery, the physician removes a horizontal strip of skin from the posterior part of the scalp. This strip is then dissected into individual grafts that are transplanted into the bald areas. Not only does this process leave a linear scar, hair from the back of the head is quite thick. Cosmetically this often looks very unnatural when used for hair replacement to reconstruct anterior hairlines.

Strip surgery has been around since the early 2000s. However, in more recent years, Follicular Unit Extraction has evolved as the more preferred and effective choice for surgical hair replacement.

In Follicular Unit Extraction, the doctor removes follicular grafts consisting of 1-5 naturally grouped clusters of hair follicles and reinserts them into the target area. This approach is capable of producing the most natural looking results, especially since the technique has evolved to include body hair (e.g. from the beard and other regions) when donor supply is limited.


Before and After of Surgical Hair Removal Transplant

F.U.E. was used to correct the hair replacement results from a prior surgery using the strip method.

FUE Hair Transplant: Will Nape Hair Survive Long-term?

For the past several years, the trusted donor source for hair transplant has been confined to a linear strip at the mid-rear scalp. This donor area falls within the safe donor area (SDA), also known as the “safe zone.” When follicular unit extraction (FUE) came along, things started to change. Surgeons could use this advanced micro-surgical technique to harvest the donor hair in individual follicular units rather than excising a whole strip of flesh. As FUE has proven its value and continued to develop, it is has become the norm for surgeons to select specific hair (from anywhere on the scalp) based on caliber, in order to get the most natural-looking results. This often means using hair from the nape of the neck to create softer, more gradual hairlines. The immediate results are undeniable, especially in comparison to hairlines made using the conventional donor strip, where hair is thickest. But people want to know if nape hair is safe for long-term graft survival or if it will fall out more quickly than traditional donor hair.

Dr. Umar’s Use Of Nape Hair

Dr. Umar is a world-leading follicular unit extraction surgeon. He is a recommended surgeon on the widely respected online patient community the Hair Transplant Network, where a member recently raised this very topic. The question was even specifically targeted toward Dr. Umar, as his impressive FUE and use of nape hair is creating a buzz.

It’s no wonder people are inquiring about non-traditional donor sources—who would want to have a hair restoration transplanting nape hair to later find out that the long-term graft survival rate is low? Patients want hair that looks great, and that will last permanently. Dr. Umar’s reply to the online community is reassuring—through his years of practice and experience, he confirms that nape hair is not always DHT susceptible, regardless of its location outside the SDA. In fact, it is more resistant to DHT than hair in the balding areas and is ideal with regard to the artistry of hair restoration. He has transplanted nape hair with lasting success to refine hairlines, and has even used other non-traditional donor sources (such as facial or chest hair, with body hair transplant) for those whose baldness is beyond the correction capabilities of strip harvesting.

Regardless of what a hair transplant surgeon recommends, it is up to the patient to decide if he trusts a non-traditional donor source like nape hair. It is true that the use of non-SDA hair hasn’t been around as long, but Dr. Umar’s results are showing long-term promise.

Nape Hair

FUE hairline refinement using nape hair.


Follicular Unit Extraction: A Multi-Faceted Method

Follicular unit extraction (FUE) is a method of hair transplantation that was first invented in the 1980’s and blossomed into global use in the 1990’s. With this sophisticated technique, surgeons harvest hair by grafting follicular units one by one from the donor pool. This means:

  • A minimally invasive surgery
  • Donor hair is not confined to the mid-back portion of the head
  • No staples, stitches, or sutures of any kind
  • No more linear scarring (as with strip harvesting)
  • A quicker healing time than other methods

FUE Branches Out

With the advent of follicular unit extraction, another major advantage followed suit: the vast potential for development and further use. There are several ways in which follicular unit extraction has been refined or expanded to reach a broader scope of hair loss sufferers. Today, FUE is a multi-faceted technique branching out into:

  • Eyebrow transplantation: the use of specifically selected donor hairs to restore thin or bald eyebrows. People may lose eyebrow hair for congenital reasons, an accident, or over-plucking. Ideal donor hair comes from the legs.
  • Hairline Design or Hairline Refinement: the use of nape hair or other fine hair to build a softer more gradual hairline. Often done as a corrective procedure after another surgery.
  • Body hair to head transplant: an advanced form of FUE that incorporates the use of body hair for donor sources. This can include the beard, shoulders, chest, stomach, arms, and legs.
  • Facial hair to head transplant: an advanced form of FUE that incorporates the use of only or mostly beard hair as the donor source.
After BHT Surgery a Multi Faceted Method

Leg healed after BHT surgery with cosmetically negligible scarring.

What Is Follicular Unit Extraction?

The Origin Of Follicular Unit Extraction

In the early 1900s hair loss became a prominent enough problem for someone to develop a technology to combat the condition. The dawn of hair restoration developed in Japan during this time, and has continued to evolve ever since. We have seen scalp reduction, flap surgery, and in the 1950s we saw the first of hair transplantation with punch grafting. Hair transplantation itself has come a long way; from the punch graft, to strip surgery, and now, to follicular unit extraction (FUE).

The follicular unit extraction technique first came about in the 1980s, also in Japan. It was an improvement of the punch grafting method, which used 4mm punch grafts for hair transplant. The result with punch graft hair transplantation was always unnatural and pluggy hair, with 4mm round bald scars in the donor area (generally the back of the head). To vastly improve results, they refined the size of the grafting area, making it much smaller and more precise. But what is follicular unit extraction, really?

How Follicular Unit Extraction Is Done

Follicular unit extraction is the removal of hairs from the donor area, generally being the back and/or sides of the head, in follicular units—natural groups of one to four hairs. These follicular units are then implanted into the recipient area, which is usually the crown, hairline and temple points.

Follicular unit extraction requires a highly skilled practitioner, as surgery is long, laborious, and detailed. FUE hair transplant surgeons generally use a manual handheld device resembling a pen to excise the follicular units one by one. Of late, there have been campaigns for powered follicular unit extraction machines, such as the NeoGraft and Artas.

Due to technical limitations, it is difficult for such systems to address finer details needed for a highly successful outcome.

This is why the use of these automated tools is strongly opposed by advanced FUE hair transplant surgeons.

The Advantages of Follicular Unit Extraction Over Strip Surgery

On the matter of hair transplantation, the superior between FUE and strip surgery is a popular debate. There are many reasons one researching hair transplantation will find that follicular unit extraction is the better choice. Some of those reasons include:

  • Follicular unit extraction avoids leaving an embarrassing linear scar.
  • The tiny, individual incisions made during follicular unit extraction result in cosmetically insignificant scarring.
  • Follicular unit extraction is a less invasive hair transplant procedure, thus the recovery time is quicker.
  • Follicular unit extraction makes it possible to extract specifically chosen hairs, such as those from the nape of the neck or behind the ears, to design a most natural-looking hairline.
  • Follicular unit extraction widens the pool of donor hair by enabling body hair transplantation (BHT).
  • Those who were once considered poor hair transplant candidates due to a depleted donor pool are now in the running due to BHT.

Eyebrow Restoration – How Does It Work?

Eyebrow restoration used to be limited to helping burn victims, but time and advances in technology has seen it evolve into a cosmetic option popular with both men and women looking to reshape and rejuvenate their eyebrows.

Your eyebrow hairs grow from the follicle at a sharp angle, so unlike the hairs on your head, your eyebrow hair is growing flat against the surface of your skin. The growth cycle of your eyebrow hair is also far shorter than that of the hairs of your scalp – about four months, as compared to three to seven years. Unlike your scalp hair, your eyebrow hairs grow as individual strands; there are no follicular groups of hairs in a bunch that can be moved from one area to another. Typically, 50 to 325 hairs are individually moved into the brow during the procedure, another reason a skilled surgeon is needed to perform this delicate task. The hairs must be perfectly placed into tiny incisions that are at just the right angle and direction to mimic natural growth.

Follicular Unit Extraction is an excellent approach for eyebrow restoration, because it involves transplanting individual strands of hair from another part of your body to your eyebrow area, leaving no visible scarring. The new hair will look a little different from your original eyebrows and have a different growth rate, but over time it will begin to mimic your existing eyebrow hair.

The procedure usually takes two hours and is done while you are under a mild sedative.

Have more questions about ways to improve your eyebrows? Contact Dr. Umar for a free online consultation today.

Strip Surgery Scarring – Can It Be Fixed?

Strip surgery is one of the most ineffective ways to restore hair loss. It involves strip mining hair from the sides and the back of the head for transplant to the problem area, but it leaves scarring and lasting pain in its wake. Too, it often leaves you in need of more surgery when the strip method fails to provide a satisfactory solution to your hair loss.

The patient featured in this video came to Dr. Umar after two different clinics left him with painful strip scars along the side and back of his head. Using the Single Follicle Extraction and Transfer procedure to transplant hair from the patient’s beard into his head, Dr. Umar was able to improve the appearance of the scar.

Have more questions about options to strip surgery? Contact Dr. Umar for a free online consultation today.